- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.13 / $2,326.13 / $3,628.76
| Facility | | $2,326.13 | $2,326.13 | $3,628.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.52 / $2,326.13 / $2,326.13
| Professional | | $2,093.52 | $2,326.13 | $2,326.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,717.05 / $1,717.05 / $1,717.05
| Facility | | $1,717.05 | $1,717.05 | $1,717.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.20 / $1,717.05 / $1,909.88
| Professional | | $1,631.20 | $1,717.05 | $1,909.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,984.34 / $2,984.34 / $3,730.43
| Professional | | $2,984.34 | $2,984.34 | $3,730.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.13 / $2,326.13 / $4,274.26
| Facility | | $2,326.13 | $2,326.13 | $4,274.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.13 / $2,350.62 / $2,938.27
| Professional | | $2,326.13 | $2,350.62 | $2,938.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,469.14 / $2,448.56
| Professional | | $1,028.40 | $1,469.14 | $2,448.56 |